Manager of Psychiatric - Utilization Review - RN/LCSW/LMT (Bellflower) in Bellflower at Los Angeles Community Hospital

Date Posted: 2/4/2021

Job Snapshot

Job Description

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Manager, Psychiatric – U.R.

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Manager, Psychiatric - UR is responsible for overseeing the daily operations of the Utilization Review department.  Ensures operations are completed in a timely manner and in accordance with all state and federal healthcare regulatory guidelines.  Works closely with the facility Physician Advisor and work collaboratively with health care team, patients and families, administration, and members of the Medical Staff.  Keeps facility administration aware of any daily operational / physician related issues.  Responsible for active participation in daily weekday intra disciplinary patient rounding.  Under the direction of the Administrator is responsible for employee coaching, training, hiring, counseling/discipline, performance assessment and payroll processes.



Job Responsibilities/Duties

  • Manages the daily operations of the UR Department, troubleshooting and resolving issues as they occur. Partners with Administration to implement strategic plans, unit/department goals and objectives, and business initiatives.  Assumes responsibility for management decisions determined within the scope of this job description.  Complies with all policies/procedures, applicable laws and regulatory agency requirements, and organization work standards. Maintains records in compliance with legal and regulatory requirements.
  • Oversees processes and ensures that all work is completed daily and in a timely manner. Manages and participates in the daily operations of the department that includes ensuring the completion of TARs for assigned Medi-Cal patient population and obtaining authorizations for managed care accounts and submits appeals for all denied cases. Ensures Medical Necessity (MN) for patient admission and concurrent stay at the short-term acute hospital level of care are met, utilizing the facility approved non-MD reviewer guidelines. Communicates as appropriate to the payer. Refers all cases not meeting MN for second level review. Ensures a safe and timely discharge / transition to the next appropriate level of care for discharging patients.  Enters delays in service and avoidable days regarding exceeded payer LOS variances.   Demonstrates problem-solving, critical thinking, and prioritization of work to resolve issues as they arise.  Maintains confidentiality of all information according to Hospital Policy and Procedure and legal and regulatory requirements.
  • Reviews hospital admissions and continued stays in accordance with procedures, criteria, and standards approved by the medical staff. Identifies opportunities for improvement in the current processes and procedures.  Escalates unresolved issues to Administrator per escalation process.
  • Ensures UR collaboration with Social Services, Clinical Team, patients, and their families to prepare patient’s discharge planning needs. Oversees appropriate DC documentation. Works with Social Service to perform a variety of miscellaneous services, such as arranging for discharge or post-hospital plans, placement of patients in skilled nursing facilities or board and care homes. Oversees that patients and their significant others understand medical recommendations through individual or group conferences. Supports patient rights and patient choice.
  • Oversees collection and reporting of data for quality assessment/improvement activities. Maintains good rapport and open communication with CM staff, Medical Staff, internal and external customers.
  • Creates a safe work environment that fosters respect and positive morale.  Effectively allocates and evaluates department work and provides leadership and appropriate follow through to the Department.  Effectively communicates with all staff.  In cooperation with the Administrator, interviews applicants and manages the hiring, firing, training, employee engagement, annual performance evaluations and competencies, and disciplinary process at assigned locations.


Qualifications

Minimum Education: None. 

Minimum Experience: Two (2) years of experience in utilization review/management in a managed care or hospital setting required. Demonstrated leadership experience. Knowledge of The Joint Commission and Title XXII regulations. Knowledge of CMS, MCARE, MEDI-CAL and Managed Care Reimbursement. Knowledge in insurance authorization and verification. Knowledge of Interqual and /or Milliman Care criteria. Excellent written and verbal communication skills in English. Computer/EMR Proficiency required. Three (3) years clinical experience in psychiatric hospital setting, with at least one year of supervisory experience preferred. Care Management Proficiency with Milliman Care Guidelines or Interqual preferred.

Req. Certification/Licensure: Current Licensure as a Registered Nurse or LCSW or LMT  in the State of California required. AHA Basic Life Support required. De-escalation certification upon hire required. Hospital Fire and Life Safety Card (Los Angeles City Employees only) required.



Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals, benefit eligible positions will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance


How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www.eeoc.gov/

Keywords: Case Management, Utlization Review, UR, Acute Care Hospital



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